The second fatal impact: cigarette smoking, chronic disease, and the epidemiological transition in Oceania

Declines and Plateaux in Smoking Prevalence Over Three Decades in Fiji

Objectives

To examine trends from 1980 to 2011 in daily tobacco smoking by sex, ethnicity, age, and urban/rural in Fiji Melanesian (i-Taukei) and Indian adults aged 25–64 years.

Methods

Unit record data from five population-based surveys (n = 14 528) allowed classification of participants as: (1) never-smoker, ex-smoker, or non-daily smoker; or (2) daily smoker, reporting smoking <20 or ≥20 tobacco products (cigarettes/cigars/pipes) a day. Trends were examined using spline analyses.

Results

Over 1980–2011 the prevalence of reported daily tobacco smoking decreased significantly in both sexes and ethnicities, with the greatest decline during 1980–2000. Declines were from 81.7% to 27.0% in i-Taukei men; 55.3% to 26.3% in Indian men; 48.1% to 9.5% in i-Taukei women; and 13.8% to 1.3% in Indian women (p < .0001). Declines were consistent across all age groups in men, while there were greater declines among older age groups in women; and greater declines from higher prevalences in rural compared to urban areas in both sexes and ethnicities. Smoking ≥20 tobacco products per day declined significantly in i-Taukei men from 8.0% to 1.9% (p < .0001); there were also declines in Indian men (4.6% to 2.0%) and i-Taukei women (2.6% to 0.6%), but these were not statistically significant; and Indian women remained <0.2% throughout the period.

Conclusions

Significant declines in daily tobacco smoking have occurred in Fiji in both sexes and ethnicities during the past 30 years, which is consistent with declines in tobacco apparent consumption and household expenditure. However, prevalence remains high in men at around 27% in 2011, with plateau at this level in i-Taukei.

Implications

This is the first study to show nationally representative population trends in tobacco smoking in a developing country over such a long period (>30 years) based on empirical unit record data (n = 14 528). Cardiovascular disease is a leading cause of mortality throughout the Pacific Island region. This is the first study to show evidence of substantial declines over several decades in a cardiovascular disease risk factor in a Pacific Island country, and provides important evidence for further research into the interventions and events which may have facilitated this decline.

Tobacco industry globalization and global health governance: towards an interdisciplinary research agenda

Shifting patterns of tobacco production and consumption, and the resultant disease burden worldwide since the late twentieth century, prompted efforts to strengthen global health governance through adoption of the Framework Convention on Tobacco Control. While the treaty is rightfully considered an important achievement, to address a neglected public health issue through collective action, evidence suggests that tobacco industry globalization continues apace. In this article, we provide a systematic review of the public health literature and reveal definitional and measurement imprecision, ahistorical timeframes, transnational tobacco companies and the state as the primary units and levels of analysis, and a strong emphasis on agency as opposed to structural power. Drawing on the study of globalization in international political economy and business studies, we identify opportunities to expand analysis along each of these dimensions. We conclude that this expanded and interdisciplinary research agenda provides the potential for fuller understanding of the dual and dynamic relationship between the tobacco industry and globalization. Deeper analysis of how the industry has adapted to globalization over time, as well as how the industry has influenced the nature and trajectory of globalization, is essential for building effective global governance responses. This article is published as part of a thematic collection dedicated to global governance.

Eliminating tobacco-related disparities among Pacific Islanders through leadership and capacity building: promising practices and lessons learned

Tobacco remains a major risk factor for premature death and ill health among Pacific Islanders, and tobacco-related disparities persist. Eliminating these disparities requires a comprehensive approach to transform community norms about tobacco use through policy change, as contained in the World Health Organization international Framework Convention on Tobacco Control. Three of the six U.S.-affiliated Pacific Islands-the Federated States of Micronesia, Palau, and the Marshall Islands-are Parties to the Framework; the remaining three territories-American Samoa, the Commonwealth of the Northern Mariana Islands, and Guam-are excluded from the treaty by virtue of U.S. nonratification. Capacity building and leadership development are essential in achieving policy change and health equity within Pacific Islander communities. We describe promising practices from American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, Guam, and Palau and highlight some of the key lessons learned in supporting and sustaining the reduction in tobacco use among Pacific Islanders as the first step toward eliminating tobacco-related disparities in these populations.

Carolina in the Carolines: a survey of patterns and meanings of smoking on a Micronesian island

Tobacco use--especially smoking industrially manufactured cigarettes--kills nearly 5 million people annually and is the leading preventable cause of death worldwide. Tobacco is a widely used global commodity embedded in cultural meanings, and its consumption involves a set of learned, patterned social behaviors. Seemingly, then, tobacco offers a most appealing anthropological research topic, yet its study has been relatively ignored by medical anthropologists when compared to research on alcoholic beverages and illegal drugs. To help fill this gap, this article sketches the historical background of tobacco in Micronesia, presents the results of a cross-sectional smoking survey from Namoluk Atoll, and describes contemporary smoking patterns and locally understood symbolic associations of tobacco. Intersections among history, gender, local meanings, the health transition, and the transnational marketing of tobacco are addressed, and cigarette smoking is seen as part of a new syndemic of chronic diseases in Micronesia.

Tobacco prevention in the Federated States of Micronesia

The impact of tobacco-related illnesses in the Federal States of Micronesia (FSM) is discussed and documented for the 1970-95 period using national government statistics and gleanings from the research literature. Based upon international data concerning tobacco-related morbidity and mortality it is estimated that 15% of 1993 FSM mortality was smoking-related and that tobacco use contributes heavily to the non-communicable diseases that are the leading causes of death there. Sources and brands of cigarettes sold in the four FSM states are noted, as is the fact that cigarettes ranked among the top five import commodities in dollar value in the mid-1980s and early 1990s. Trend data are provided on cigarette imports from 1984 to 1993, during which time FSM citizens spent over US$25.5 m on this legal drug. Brand-price survey data of cigarettes and selected foodstuffs are presented as part of a discussion of the economic opportunity costs of smoking. Tax revenues from cigarettes are recorded, as are the steps toward smoking prevention and tobacco control taken by the FSM government. The article concludes with suggestions for additional controls that might be implemented.

Epidemiological transition: model or illusion? A look at the problem of health in Mexico

This paper discusses the validity of the epidemiological transition model to interpret changes in the structure of mortality and morbidity. Epistemological and political questions are posed. The case of Mexico is used to illustrate the limitations its use imposes on understanding the constellation of components explaining the epidemiological profile, and the problems involved in designing a public health policy on the basis of this sort of misinterpretation. It is suggested that the illusory certainty of a pre-determined destiny distorts the prospective that would enable to construct scenarios; what is actually happening remains hidden by the model and health policies are designed without adequate parameters for evaluating their effective impact. We conclude with some remarks on the usefulness of constructing alternative forms of interpretation for understanding changes in the epidemiological profile, one of the most important inputs for designing better policies to face the challenges posed by health care and dealing with illness in modern-day societies.

Slowing the epidemic of tobacco use among Asian Americans and Pacific Islanders

Data on tobacco use among the Asian American/Pacific Islander (AAPI) population remain limited, although existing studies indicate that tobacco use prevalence among males from specific AAPI groups is significantly higher than in the general US male population. This high prevalence of tobacco use and the disparities in use result from social norms, targeted marketing by the tobacco industry, lack of culturally and linguistically tailored prevention and control programs, and limited impact of mainstream tobacco control programs for AAPIs. We review the available literature on tobacco use among AAPI men and women, highlight a national agenda that promotes tobacco prevention and control for AAPI communities, and acknowledge recent trends including the increase of tobacco use among AAPI women and girls.

Targeting of Asian Americans and Pacific Islanders by the tobacco industry: results from the Minnesota Tobacco Document Depository

OBJECTIVE

The study objective was to review internal tobacco industry documents written between 1985 and 1995 regarding the Asian American and Pacific Islander (AAPI) population in the USA. These documents detail opportunities and barriers to promotion of tobacco products, as viewed by the tobacco industry and its market research firms.

DATA SOURCES

/methods: Researchers reviewed tobacco industry documents from the document depository in Minneapolis, Minnesota and the tobacco industry's website, The Tobacco Archive, in a systematic fashion. A combined technique was employed using title keywords, dates, and names to search the 4(b) index.

FINDINGS

A review of internal tobacco company documents reveal that during the late 1980s, the industry and its market research firms recognised the importance of the AAPI community as a potential business market. Documents describe the population growth in this community, the high prevalence of smoking in countries of origin, high purchasing power of AAPI immigrants, cultural predisposition to smoking, opportunities afforded by the high proportion of retail businesses under AAPI ownership, barriers to developing the AAPI market, comprehensive campaigns, and political and lobbying efforts. Comprehensive campaigns were designed to integrate promotion efforts in AAPI consumer, retail, and business communities.

CONCLUSIONS

The documents show that the tobacco industry developed specific promotion strategies to target the AAPI population. Tobacco control initiatives in the AAPI group have been slower to develop than in other targeted ethnic groups, and may benefit by increased awareness of industry methods to promote tobacco use.

Anthropological perspectives on alcohol and drugs at the turn of the new millennium

This introduction to the collection provides our thoughts on where alcohol and drug studies in anthropology are going as we enter the new millennium. After commenting briefly on each of the papers that comprise the rest of the volume, we discuss what we see as the most important and exciting issues in the future and give our views on what alcohol and drug studies can offer to medical anthropology, anthropology writ large, interdisciplinary and multidisciplinary research, and the realm of public policy and practical affairs. We call for a continued study by anthropologists of the whole array of pharmacologically active substances used by humans in different parts of the world, whether or not such studies are situated within medical anthropology. We note that many of these substances have received little attention from anthropologists to date, quite strikingly so in the cases of substances such as marijuana and methamphetamines. We emphasize that most scholars working in the anthropology of alcohol and drugs are concerned with the application of their findings to social problems, and we note that this has been especially true of research on alcoholic beverages and injection drugs. This leads us to a discussion of anthropology's involvement in public health intervention and policy work in a variety of settings. Such involvement is shown to have informed anthropological theory (notably political economic approaches) and to have enriched the methodological toolkits and forms of data analysis anthropologists use. Perhaps more importantly, we argue that such multidisciplinary involvement in applied work is most likely to eventuate in theoretical progress in alcohol and drug studies, since theory in the social sciences is not bound to singular disciplinary approaches. Thus we advocate for a "hybrid vigor" in this specialty area in the years ahead.

Going like gangbusters: transnational tobacco companies "making a killing" in South America

This article reports on the recent growth of transnational tobacco companies (TTCs) in South America. Although some scholarly attention has been directed toward such growth in Asia and eastern Europe, South America has also been targeted by the TTCs' aggressive expansionist practices in recent years. Fighting "Big Tobacco" is entirely different from combating most public health problems. Unlike cigarettes, most infectious diseases and maternal and child health problems never provide profits to transnational corporations and governments. Also, most public health problems (with alcohol being another notable exception) are not exacerbated by extensive advertising campaigns that promote the cause of the health problems. Supported by data gathered during three months of fieldwork in Ecuador, Peru, Chile, and Argentina in 1997, this article suggests that the TTCs' marketing strategies override cultural differences in the choices people make regarding smoking and health. Combining critical medical anthropology and public health, this article concludes that unless dramatic actions are taken, an avoidable outbreak of tobacco-related diseases will eventually reach epidemic proportions on the South American continent. It is also a "call to arms" for more medical anthropologists to investigate tobacco-related matters around the world.

Measuring support for tobacco control policy in selected areas of six countries

OBJECTIVE

To explore the validity, reliability, and applicability of using a short, psychometrically sound survey instrument to measure population attitudes toward tobacco control policies.

DESIGN

Surveys.

SUBJECTS AND SETTING

Student respondents attending university in Australia (n = 403), Hong Kong (n = 336), the Netherlands (n = 351), South Africa (n = 291), the United Kingdom (n = 164) and the United States (n = 241); total n = 1786.

MAIN OUTCOME MEASURE

The Smoking Policy Inventory (SPI), a 35-item scale. SPI scores were adjusted for age, income, gender, and smoking status. Estimates of internal consistency and tests of factorial invariance were conducted in each sample.

RESULTS

Across all six countries, the SPI was found to be highly reliable and to have a consistent factor structure, indicating that the SPI scale represents a higher order construct that assesses general attitudes about tobacco control policy with five dimensions. In general, the degree of endorsement of anti-tobacco policies as measured by the SPI reflected the extent and strength of tobacco control legislation in those countries. Dutch students were the least likely, and Australian and Hong Kong students the most likely, to support tobacco control policies.

CONCLUSIONS

It is possible to develop appropriate and meaningful measurement tools for assessing support of tobacco control policies. Strong evidence was found for internal reliability and structural invariance of the SPI. The SPI may be a useful mechanism for monitoring ongoing policy initiatives, making cross-cultural comparisons, and evaluating population receptiveness to proposed policy approaches.

Tobacco control in a traditional Fijian village: indigenous methods of smoking cessation and relapse prevention

This case study outlines the unique process by which a village in Fiji (N = 238) developed and implemented an extremely successful community-based smoking cessation program. Both Western smoking cessation methods and native traditional rituals were used. Specific strategies included a group pledge, village rapid inhalation ceremony, social contracting through notices and media, and a tabu formalized through a kava ceremony. Whereas the more conventional, external, health professional oriented approaches were largely unsuccessful, longer term collaborative and village empowerment methods proved most successful. Eventually all persons in the village who smoked were able to give up smoking, with specific exceptions (elders, visitors, etc.) and became nationally known as the village that gave up smoking. Follow up evaluation at 9 and 21 months indicated sustained success. Cases of relapse are described involving supernatural consequences remedied by group and ceremonial methods. The socio-cultural context and larger relationship issues are discussed in order to more fully understand the effectiveness of the program.